INTRODUCTION: Asthma is the most prevalent chronic disease in children, disproportionately affecting children from racial or ethnic minority groups and low-income families. Boston Medical Center’s Pediatric Primary Care Center serves these patient populations predominantly from the surrounding neighborhoods. It has been found that there are gaps in asthma care including diagnosing asthma in infants and young children, under-prescribing of preventive medication in all age groups, and variable management of children with poorly controlled asthma. In alignment with the accountable care organization model, health care professionals at BMC are using evidence-based care and population-based approaches to reduce asthma morbidity and thus improve the quality of life for patients with asthma and their families. METHODS: A quality improvement initiative was conducted at BMC’s Pediatric Primary Care Center. The aim was to develop routine surveillance of asthma control for the clinic population in order to identify and intervene on patients who have poorly controlled asthma. The Asthma Control Test (ACT) and the Test for Respiratory and Asthma Control in Kids (TRACK) were adapted into practice as validated patient-parent-reported tools to use to assess asthma control at all primary care office visits. Process measure included the percentage of visits with a documented asthma control testing in the electronic medical record. Outcome measures included (1) percentage of patients with poorly controlled asthma presenting to the clinic, as indicated by low ACT/TRACK scores, and (2) percentage of visits with a documented provider action in response to low ACT/TRACK scores. Iterative Plan, Do, Study, Act (PDSA) cycles optimized results; process and outcome measures were analyzed on run charts for trends. RESULTS AND CONCLUSIONS: Patient-centered strategies for visits and population-based systems to analyze outcomes are effective at delivering quality care for BMC’s pediatric asthma patient population. Following the implementation of routine asthma control screening in primary care, the percentage of visits with documented ACT/TRACK scores went from a baseline of 8% to 86%. Week to week variation was mostly attributed to higher patient visit volume beginning in the Fall season when epidemiologically there is a substantially increased frequency of asthma exacerbations in children. A median of 23% of patients report poorly controlled asthma during their visit. The percent of visits with documented provider action increased from 87% to 95% during this quality improvement initiative, indicating that patients were receiving targeted care needs including medication management and asthma education in response to low ACT/TRACK scores. However, consistent and timely delivery of preventive care services continues to be a challenge, particularly for a clinic serving high-risk, underserved, and culturally diverse patient populations. / 2020-06-17T00:00:00Z

BACKGROUND: Asthma is a chronic inflammatory disease of the airways that disproportionately affects low-income and minority children in the United States. Some studies have found a clear link between poor housing quality and exposure to allergen triggers associated with increased risk of asthma. Other studies have evaluated the relationship between stressful circumstances due to chronic illness, premature birth or violence on asthma outcomes. Psychological stress is thought to weaken the immune and neuroendocrine response making the body more vulnerable to environmental allergens. Studies have been done to assess the impact of psychological stress due to violence or the care of long term-critically ill children on increased asthma morbidity. However, asthma morbidity is not equal in all low-income and minority communities. It is possible that a form of stress - housing stress - which results from living in substandard housing conditions, may in fact provide more insight into the pathways linking indoor home exposures and stress in a way that leads to greater asthma susceptibility. Few studies have been done to assess the impact of stress due to substandard housing conditions. OBJECTIVE: To determine the impact of severe housing stress due to dilapidation, mold and a lack of housing control on child asthma control and on caregiver asthma-related quality of life. METHODS: A total of 143 children with asthma living in Boston, Massachusetts and between the ages of 4 and 18 were enrolled in the Boston Allergen Sampling Study between 2008 and 2011. Home visits were conducted to measure the levels of common allergens in the home and assess child asthma control, housing stress, perceived stress, and caregiver asthma-related quality of life. Housing stress was assessed based on resident perceptions of dilapidation, mold, and a lack of housing control; perceived stress for the caregiver was assessed using the Perceived-Stress Scale (PSS); child asthma control was assessed using Asthma Control Test (ACT) scores; and caregiver asthma-related quality of life was assessed using the Pediatric Asthma Caregiver Quality of Life (PACQOL) questionnaires. RESULTS: In a multivariate logistic regression severe housing stress was associated with 7.5 times increased odds of poor asthma control (OR = 7.51, 95%CI 2.7 to 20.79, p<0.0001) for the child and 3.0 times increased odds of poor caregiver asthma-related quality of life (OR = 3.02, 95%CI 1.37 to 6.63, p<0.006). This association was significant after adjusting for potential confounders. CONCLUSIONS: Independent of allergen exposure, the association between severe housing stress and asthma health outcomes for both the child and caregiver indicate that there is an emotional stress-based pathway directly tied to poor housing quality that poses increased risk for worse asthma health outcomes.